INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on November 15, 2021 through November 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Parkside Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a physical plant inspection, conducted at approximately 9:30AM on November 16, 2021, the facility failed to have hot water under pressure in the facility bathrooms. In the men ' s bathroom on the second floor, there was no running hot water in the sink closest to the entry door. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director reached out to facilities on November 18, 2021, to request the bathroom sink be fixed in order to fix the hot water. During routine safety checks, water temperature will continued be monitored as this has been added to the safety checklist. Facilities will continue to be notified if any other issues related to water pressure or temperature arise |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of personnel records, the facility failed to ensure that the records included documentation of an annual written individual performance evaluation, which is to be reviewed and signed by the employee, in two of twelve employee records reviewed.Employee # 4 was hired as a clinical supervisor on April 2, 2019. There was no documentation that an annual written individual performance evaluation was completed as of the date of the inspection.Employee # 5 was hired as a clinical supervisor on January 1, 2020. There was no documentation that an annual written individual performance evaluation was completed as of the date of the inspection.These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
Moving forward, following completion of all staff performance evaluations, the original copy will be sent to each staff's HR file. A copy of the evaluation will be securely kept in the Facility Director's office |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on a review client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed.Client #3 was admitted on June 16, 2020 and was active at the time of inspection. There was an informed and voluntary consent to the funding source, signed and dated by the client June 16, 2020, with an expiration date of June 16, 2021. There was evidence of disclosures after the consent expiration date and there was no current consent form completed prior to any of the disclosures. Client #5 was admitted on April 26, 2018 and was discharged May 5, 2021. There was an informed and voluntary consent to the funding source, signed and dated by the client August 14, 2019, with an expiration date of August 14, 2020. There was evidence of disclosures after the consent expiration date and there was no current consent form completed prior to any of the disclosures.Client #6 was admitted on July 11, 2018 and was discharged October 22, 2021. There was an informed and voluntary consent to the funding source, signed and dated by the client July 11, 2018, with an expiration date of July 11, 2019. There was evidence of disclosures after the consent expiration date and there was no current consent form completed prior to any of the disclosures. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations, have not expired, and are completed in their entirety. Clinical Supervisors and Program Director will also review, and provide feedback as needed, during supervision. Intake packets and consents will also be reviewed following the completion of intake, to ensure documentation is being completed appropriately and in its entirety. The Project will retrain staff on how to accurately complete consents by December 31, 2021. At this training visual aids and templates will also be provided to staff that will display how a consent should be completed, and what entities should be marked in order to document what specific information will be released. Staff will be encouraged to utilize these visual aids and tools as they complete consents in order to ensure their consents are being completed efficiently and in their entirety. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure would be made to on informed and voluntary consent forms in two of seven client records reviewed.Client #1 was admitted on October 30, 2020 and was active at the time of inspection. A release of information form was signed and dated by the client; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made. Client #4 was admitted on March 30, 2021 and was active at the time of inspection. A release of information form was signed and dated by the client; however, the consent forms did not include the specific name of the person, agency, or organization to whom the disclosure was to be made. The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations, have not expired, and are completed in their entirety. Clinical Supervisors and Program Director will also review, and provide feedback as needed, during supervision. Intake packets and consents will also be reviewed following the completion of intake, to ensure documentation is being completed appropriately and in its entirety. The Project will retrain staff on how to accurately complete consents by December 31, 2021. At this training visual aids and templates will also be provided to staff that will display how a consent should be completed, and what entities should be marked in order to document what specific information will be released. Staff will be encouraged to utilize these visual aids and tools as they complete consents in order to ensure their consents are being completed efficiently and in their entirety. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to identify the specific information to be disclosed on consent to release information forms in four of seven client records reviewed.Client #1 was admitted on October 30, 2020 and was active at the time of inspection. There were consent to release information forms to a funding source, a transportation service, and a recovery house that did not document the specific information to be released. Client #3 was admitted on June 16, 2020 and was active at the time of inspection. There was a consent to release information form to an emergency contact that did not document the specific information to be released. Client #4 was admitted on March 30, 2021 and was active at the time of inspection. There were consent to release information forms to a funding source, an emergency contact, a transportation service, and a recovery house that did not document the specific information to be released. Client #7 was admitted on July 8, 2020 and was discharged September 16, 2021. There was a consent to release information form to an emergency contact that did not document the specific information to be released. The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations, have not expired, and are completed in their entirety. Clinical Supervisors and Program Director will also review, and provide feedback as needed, during supervision Intake packets and consents will also be reviewed following the completion of intake, to ensure documentation is being completed appropriately and in its entirety. The Project will retrain staff on how to accurately complete consents by December 31, 2021. At this training visual aids and templates will also be provided to staff that will display how a consent should be completed, and what entities should be marked in order to document what specific information will be released. Staff will be encouraged to utilize these visual aids and tools as they complete consents in order to ensure their consents are being completed efficiently and in their entirety. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to obtain the dated signature of the client on consent to release information forms in two of seven client records reviewed.Client #3 was admitted on June 16, 2020 and was active at the time of inspection. There was a consent to release information form to a funding source, signed by the client; however, the client signature was not dated.Client #7 was admitted on July 8, 2020 and was discharged September 16, 2021. There were consent to release information forms to a funding source, an emergency contact, a transportation service, and a recovery house that did not document the dated signature of the client.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations, have not expired, and are completed in their entirety. Clinical Supervisors and Program Director will also review, and provide feedback as needed, during supervision Intake packets and consents will also be reviewed following the completion of intake, to ensure documentation is being completed appropriately and in its entirety. The Project will retrain staff on how to accurately complete consents by December 31, 2021. At this training visual aids and templates will also be provided to staff that will display how a consent should be completed, which will include having a date and signature. Staff will be encouraged to utilize these visual aids and tools as they complete consents in order to ensure their consents are being completed efficiently and in their entirety. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to ensure that all informed and voluntary consent to release information forms indicated a copy of a client consent were offered to the client in one of seven client records reviewed.Client #1 was admitted on October 30, 2020 and was active at the time of inspection. A release of information form signed and dated by the client failed to document whether a copy of the form was offered to the client. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations, have not expired, and are completed in their entirety. Clinical Supervisors and Program Director will also review, and provide feedback as needed, during supervision Intake packets and consents will also be reviewed following the completion of intake, to ensure documentation is being completed appropriately and in its entirety. The Project will retrain staff on how to accurately complete consents by December 31, 2021. At this training visual aids and templates will also be provided to staff that will display how a consent should be completed, including all entities that need to be filled in and completed. Staff will be encouraged to utilize these visual aids and tools as they complete consents in order to ensure their consents are being completed efficiently and in their entirety. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on a review of patient records, the facility failed document a random urinalysis at least monthly in one of four applicable patient records reviewed.Patient #3 was admitted on June 16, 2020 and was active at the time of inspection. There was no documentation in the record that a random urinalysis was conducted for the month of July 2021.The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Project will continue to document instances when a client is in placement, or when there are barriers that prevent a client from coming to the facility which would justify a urinalysis not being completed. The Project will work on developing polices that will allow a UDS to be transported to the facility if a client is temporary residing at another level of care, such as a nursing home, in order to comply with monthly submission. |